Short on staff and funding, facilities are overwhelmed by the sickest, poorest
By Erin Hoover Barnett of The Oregonian staff
» Oregon nursing homes: more information
At the end of a hallway, behind doors with decorated name cards, are the new faces in Oregon nursing homes.
A small-framed woman, pummeled by strokes, began her stay thrashing about, ripping at her clothing, struggling to stand, crashing to the ground. Fighting mightily, she now takes tentative steps with a walker. Yet she eats through a tube. She cannot use a toilet. She cannot speak. She is 56.
On the same wing at Portland's Care Center East Health and Specialty Care Center, Carl Adels lies on a special air mattress. He can speak, smile his toothy smile and move his head, but little else. Aides help him eat and move to a wheelchair. He has multiple sclerosis. He is 48.
Across the hall is Betty Henderson, her left side weakened by a stroke. She needs two people to move her to her wheelchair for meals and bingo. She needs help to use the bathroom and to manage a complex regimen of medication. She is 85.
On any given day, Oregon's 10,000 nursing home residents are among the most disabled and vulnerable in the country, a state report concludes.
Because Oregonians have so many alternatives to nursing homes -- from in-home care to adult care homes to assisted living -- the state's 154 nursing homes are left with the sickest and often the poorest residents. And as hospitals push patients out the door sooner after major surgery or accidents, nursing homes have become rehabilitation centers for young and old, as well as places where elderly and severely disabled people live until they die.
"In nursing homes, the population 20 years ago was alert, oriented, fairly healthy ladies who were into knitting and just needed a little help putting their make-up on," said Shelley Barnes, administrator at Care Center East. "Those ladies don't live here anymore. Those people are in assisted living."
The high impairment level is at the core of nursing homes' struggle. Sicker people require more caregivers at a time when a tight labor market makes qualified workers scarce and turnover higher. Meanwhile, the state's minimum staffing requirements -- such as one nurse's aide for every 10 residents during the day -- do not reflect the heightened needs of the residents.
In addition, the average occupancy rate in Oregon nursing homes is low -- 79 percent -- causing facilities to stretch building costs across fewer people. And Oregon's Medicaid reimbursement rate -- which pays for 65 percent of people in Oregon nursing homes -- is in the bottom half nationally at $97 per resident per day.
The result: care that is uneven at best.
"Care needs of nursing home residents have grown more complex, and facilities are having increasing difficulty delivering and maintaining high-quality care to residents," concludes the state's 1999 Nursing Facility Annual Report, a recently prepared internal document that was obtained this month by The Oregonian.
The report likely will become part of legislative budget discussions next year after Gov. John Kitzhaber made long-term care a lower priority than young children and schools.
"As a regulator, I have to insist they meet the standards," said the report's author, Dan Barker, who manages the state's nursing home investigators for the Senior and Disabled Services Division. "But I have to sympathize with them, given the difficult task they have."
Meredith A. Cote, Oregon's long-term care ombudsman, was more blunt: "Right now, we have a situation where the likelihood of being in a nursing home and not getting basic needs met has increased dramatically in the last few years."
Among the report's findings:
"Just about on every front I think life is tougher for nursing homes now than it was three or four years ago," Barker said.
Care Center East's experience is typical. The 83-bed facility has greatly improved since doing poorly on its state inspection in 1999. Shelley Barnes, who took over as administrator last spring, emphasizes helping residents to guide their care and treating staff with respect.
Staff members from nurse supervisors to aides describe themselves as part of a team. Residents describe staff members as willing to go out of their way to meet their needs. Activities for those able to attend include a current events discussion in the morning and a men's group that listens to Rush Limbaugh.
More young people need care
The majority of Care Center East's residents are over 85. But a growing number are younger, sometimes including people with chronic illnesses or accident victims in their 20s, Barnes said.
Very ill residents need more intensive care, such as the 56-year-old stroke survivor. While in the hospital after her last stroke, she was in five-point restraints to keep her from thrashing and falling out of bed. Care Center East does not use restraints. To keep her safe upon her return, they put her mattress on the floor with padding around it and moved all the furniture to keep her from falling into it or impulsively climbing on it. They stationed a caregiver to be near her at all times. Her family visits daily.
If she suffers so much as a single bruise, it would unleash an internal investigation scripted by state regulators involving five separate reports to determine whether the bruise was due to abuse and to plan how to prevent future bruising.
At Care Center East, Shelly Caliman-Rogers and Judy Matz do nothing but paperwork to satisfy regulators and monitor residents' care plans. They are registered nurses who spend their time at desks, not residents' bedsides.
Staffing a constant problem
Care Center East, like most Oregon nursing homes, works daily to fend off a vicious cycle of staffing challenges. When a nursing home falls below the state staffing minimums -- one nurse's aide for every 10 residents during the day, for example -- they must hire temporary caregivers from agencies. While some of these temporary workers are well skilled, others are not, and all suffer from not knowing the residents.
The agencies tend to pay nurses and aides more than nursing homes, heightening the competition for scarce caregivers. And the agencies charge the nursing homes nearly double the caregiver's hourly rate, stretching resources thinner.
Barnes has worked hard to reach a point where, for the time being, she is using no temporary workers and is staffing above the state minimum. But she could use more caregivers.
Jim Danforth, 48, sits up in his bed overlooking the leafless trees in the courtyard. He is recuperating after parts of both feet were amputated due to diabetes. He may never walk again.
But he said the staff at Care Center East has been good to him. The nurses have let him quietly roam the halls in his wheelchair when he can't sleep at night. "They make you feel like this is a home, not a nursing home," he said.
But he sees their strain. He remembers when several caregivers were out ill. He pitched in to help his 81-year-old roommate when the man was sick and vomiting.
to work double shifts, triple shifts," Danforth said, "to make sure we
get taken care of."
You can reach Erin
Hoover Barnett at 503-294-5011 or by e-mail at firstname.lastname@example.org.